iarjmsIARJMSIARJMS2708-3594https://doi.org/10.47310/iarjms.2020.v01i02.008SARS-CoV-2 and Its Neurological ImplicationsJosefFinstererFulvio A.ScorzaKlinikum Landstrasse, Messerli Institute, Vienna, AustriaDisciplina de Neurociência. Escola Paulista de Medicine/Universidade Federal de São Paulo/. (EPM/UNIFESP). São Paulo, BrasilWith interest we read the review article by Ellul et al. about neurological abnormalities in SARS-CoV-infected patients [1]. We have the following comments and concerns.  A neurological disease not addressed in the review is myasthenia. There are several reports indicating that SARS-CoV-2 can deteriorate myasthenia [2] or even trigger myasthenic crises [3]. Since patients with myasthenia are at increased risk due to their mostly immunological disease and immune-modulatory treatment, actions need to be taken to avoid a SARS-CoV-2 infection in these patients.               Other neurological manifestations not addressed in the review are muscle cramping, tics, and tremor reported in <1% of 917 Chinese SARS-CoV-2-infected [4]. In some patients the virus may also trigger rhabdomyolysis.  We do not agree that Guillain-Barre syndrome has been reported in only in 19 patients. In a recent meta-analysis, 24 patients with polyradiculitis were presented [5]. Fourteen patients were diagnosed with AIDP, four with AMAN, three with MFS, and two with AMSAN [5]. In none of them was the virus detected in the CSF, why a cross-reaction of the immune-system against the virus and components of the radices or the extensive immunological response to the virus were made responsible [5]. Since this analysis (end of May) at least three more patients have been reported.    Encephalopathy is a hazy term indicating cerebral disease in general, that should be avoided. In a recent review of SARS-CoV-2-associated meningitis/encephalitis (submitted end of June) it turned out that the majority of the patients with SARS-CoV-2-associated encephalopathy has para-infectious, non-vascular, non-hypoxic, presumably immune-mediated CNS-disease, classified as auto-immune encephalitis (n=11), acute, hemorrhaghic, necrotising encephalopathy (n=2), or acute disseminated encephalomyelitis (n=3). No virus was found in the CSF in any of them. Only in 14/48 patients CNS-disease was classified as infectious (meningitis (n=1), encephalitis (n=5), meningo-encephalitis (n=5), myelitis (n=3)). The virus was present in the CSF in only 4/14 patients. Fifteen/48 patients received virostatics, 21 antibiotics, 11 steroids, 5 immunoglobulins, 7 plasma exchange, 8 antiepileptics, 8 chloroquine, and 11 required mechanical ventilation. Twenty-two patients recovered, 2 did not, and 6 died. In conclusion, infection with SARS-CoV-2 definitively concerns the neurologist and has therapeutic implications. Peripheral neuronal networks (pulmonary, enteric, pharyngeal, nasal) are affected before the CNS. There are indications that CNS/PNS are more widely and frequently directly or indirectly involved than anticipated. In most cases, SARS-CoV-2-associated CNS/PNS disease is immune-mediated. Thus, in most of these patients immuno-suppressive / immune - modulatory treatment, immunoglobulins, or plasma exchange should be considered.